Retained foreign body in the orbit and cavernous sinus with delayed presentation of superior orbital fissure syndrome: a case report
By Reza Jarrahy, M.D. Sung Tae Cha, M.D., Hrayr K. Shahinian, M.D., FACS
Reports of delayed onset of neurological symptoms following penetrating intracranial trauma are rare. We present the case of a patient who presented with superior orbital fissure syndrome 72 hours following reported trauma to the right eye. Subsequent workup revealed a foreign body located within the orbit, passing through the superior orbital fissure and into cavernous sinus, impinging upon the right cavernous carotid artery. Evidence of an intraorbital abscess was also present. Surgical management consisted of a combination of fronto-pterional and orbital approaches to fully expose both the cavernous sinus and the orbital contents. The foreign body was removed and the abscess was drained. The carotid artery was found to be intact. At ten month follow up examination, a slight ptosis and medial gaze of the right eye persist. All other symptoms have resolved.
This is the case of a 28 year old gentleman who presented to a local community hospital following an injury to the right eye sustained during a reported assault. The patient was unaware of what type of object he was struck with. At initial presentation he complained of sharp pain behind the right eye associated with vague symptoms of diplopia and nausea. A laceration of the right upper lid was noted on physical exam. This was sutured and the patient was discharged from the emergency room. The patient presented two days later to a second community hospital complaining of persistence of his original symptoms. A Computed tomography (CT) scan performed at that time revealed air in the orbit. Subsequent lumbar puncture yielded normal cerebrospinal fluid. He was then referred to our institution for further evaluation.
Upon arrival, the patient was complaining of a sharp constant headache at the vertex of the skull associated with abnormal eye motility. On physical exam the sutures placed at the community hospital were noted. Visual acuity was 20/40 OD and 20/30 OS. However, global ophthalmoplegia of the right eye was evident: abduction and adduction and upward gaze were markedly limited, with lesser yet significant limitation of downward gaze. The right eye also demonstrated a moderate degree of proptosis. Fundoscopic exam showed mild tortuosity of the retinal vessels and no disc edema. The remainder of the neurological exam and physical assessment were normal. The patient was admitted to the hospital and administration of intravenous ticarcillin/clavulanate was begun. The following morning visual acuity was 20/20 OD and 20/20 OS. The pupils were equal and reactive; eye pain, headache, and ophthalmoplegia persisted. There was further limitation of the oculomotor function. CT scan of the orbits and cavernous sinus documented a markedly proptotic right globe distinguished by the presence of a foreign body extending from the medial aspect of the right orbit at the inferior aspect of the medical rectus muscle (and possibly penetrating it) through the superior orbital fissure and into the cavernous sinus, ending at the posterior aspect of the sinus. This study raised the concern of possible impingement upon and damage to the right cavernous carotid artery. Additionally noted were findings in the right cavernous suggestive of thrombophlebitis as well as an area within the medial aspect of the right orbit suspicious for an abscess. The right ophthalmic vein and optic nerve were normal, and no intracranial air was seen. The foreign body appeared to be cylindrical in nature; its total anteroposterior length was measured as 5.8 cm and its width as 2-3 mm.
Magnetic resonance (MR) imaging confirmed these findings, verifying the passage of the foreign body through the superior orbital fissure and into the cavernous sinus. Magnetic resonance angiography (MRA) also raised further concerns regarding the integrity of the cavernous carotid artery; however, damage to the artery could not be unequivocally ruled in or out.
Interventional neuroradiology was consulted to help elucidate the extent of involvement of the right cavernous internal carotid artery and to evaluate the adequacy of cross filling from the left internal carotid system, should intraoperative occlusion of the right carotid become necessary. Right internal carotid artery angiogram was performed which showed an irregular narrowing of the cavernous portion of the artery. Adequate cross filling of the left internal carotid system into the right cerebral circulation was documented: the patient underwent test balloon occlusion of the right internal carotid artery, tolerating 30 minute of occlusion asymptomatically and without difficulty. Surgery was then planned to gain proximal and distal control of the right cavernous carotid artery, to remove the foreign body from the orbit and the cavernous sinus, to repair the right cavernous carotid artery as necessary, and to drain the intraorbital abscess.
In the operating room, a bicoronal flap was developed down to the supraorbital rims and the right temporalis muscle was disinserted. Fronto-pterional craniotomy was performed and bone flaps were removed. The dissection was continued inferiorly with removal of the supraorbital rim, lateral orbital rim, and zygoamtic arch. Dissection was continued along the floor of the middle cranial fossa, identifying the second and third branches of the trigeminal nerve. The latter was sacrificed. The middle meningeal artery was also identified and sacrificed. At this point, the carotid artery was identified emerging from the foramen lacerum. A balloon catheter was placed alongside the artery in the foramen: proximal control was thus achieved. The dissection was extended anteriorly and medially until the entire lateral wall of the orbit was drilled away. The superior orbital fissure was then identified and freed both medially and laterally. The optic nerve was identified and spared. The anterior clinoid process was drilled down.
At this point, the entire right orbit was exposed. Dissection was continued intraorbitally: an abscess was identified between the globe and the medial rectus muscle, and was drained. The superior orbital fissure was then opened, revealing the foreign body. The nature of the material was not readily identifiable; it was decomposed and fragmented. All pieces were removed from the fissure and from the orbit. Foreign body debris were removed from the cavernous sinus and the cavernous sinus artery was examined. There was no apparent injury to the artery and no repair was necessary.
After copious irrigation of the surgical field, the bone flap were repositioned and secured in place, the bicoronal flap was reapproximated, and the skin incision was closed.
The patient's postoperative course was uneventful. Proptosis, edema, and ecchymosis of the right eye began to diminish after four days. His neurological exam remained normal throughout the remainder of his hospital stay. He was discharged on postoperative day 9 and continued on antibiotic therapy with IV ticarcillin/clavulanate at home for an additional week. After 10 months, a slight right medial gaze and ptosis persist. Otherwise, visual acuity and oculomotor function in both eyes have returned to normal baseline status.
Presentation and initial management:
Scientific observations regarding orbital penetration by a foreign body with intracranial extension can be found dating back to the 19th century.1 Subsequent reports on the subject have been abundant. Cases of patients specifically presenting with retained intracranial foreign bodies which caused no neurological symptoms at the time of initial insult are scarce. Looking specifically at periorbital trauma with intracranial penetration by sharp wooden objects, Miller2 cites only 30 cases over the course of 150 years where the onset of neurological symptoms were significantly delayed from the time of original insult. The vast majority of these patient were in the pediatric population, with a mean age of approximately 10 years.
Our patient presented to a community hospital offering a poor history regarding the events surrounding the trauma he sustained. His symptoms were nonspecific and he was deemed to have no significant neurological deficits at that time. Within 72 hours, however, the patient presented with the following signs: periorbital edema, proptosis, ophthalmoplegia, and normal papillary and corneal reflexes. There were no sensory abnormalities in the distribution of either first or second branches of the trigeminal nerve. Based upon this presentation, the suspicion for superior orbital fissure syndrome was high. The syndrome is characterized by the presence of periorbital edema, proptosis, subconjuctival ecchymosis, ptosis and ophthalmoplegia, dilatation of the pupil, absence of direct light reflex, loss of the corneal reflex, and cutaneous anesthesia or hyperesthesia of the forehead region. Incomplete forms of this syndrome, however, can be found; clinical presentation varies according to the extent of involvement of the structures found in the region of the superior orbital fussure.3
Radiological workup, including both CT and MRI modalities, very clearly illustrated the source of our patient's symptoms. The usefulness of CT imaging of the orbit in the setting of trauma is well described, especially to visualize the bony anatomy of the orbit and skull.4,5 The addition of MR to the armamentarium of the surgeon allows for unsurpassed depiction of the clinical anatomy of the orbit, especially in the apical region.6 Furthermore, MRA provides a less invasive means than conventional angiography to document blood flow when vascular injury is suspected. When MRA is inconclusive, however, or when documentation of contralateral filling capacity of the uninvolved carotid artery is necessary, angiographic depiction of the vascularure remains the gold standard.7
The complexity of the cavernous sinus and its regional anatomy has discouraged aggressive surgical management of lesions in this area until only relatively recently. Concerns with damaging vital neurovascular structures have traditionally limited attempts to resect even confined lesions. The work of Parkinson, however, contested the notion of the surgical inaccessibility of the cavernous sinus and the cavernous carotid artery.8 Advances in the sophistication and quality of interventional neuroradiology, microsurgical techniques, and neurovascular anatomical studies9 have helped establish surgery of the skull base as a standard therapeutic option in the management of lesions that involve this area. Published reports uniformly stress technical and anatomical expertise as a prerequisite to any surgical manipulation in this region.9,10
Several standard surgical approaches to the cavernous sinus have been described, as have approaches to the orbit.8,11-13 Most of these, however, are based upon clinical experience with the removal of tumors or vascular lesions invading these spaces. No singular approach has been proposed for the management of traumatic injury to the orbit or cavernous sinus: based upon the nature of the insult, the surgeon must adapt a flexible approach to preoperative planning and intraoperative execution, depending on the surgical findings. In the case that we present, preoperative workup identified several problems that would influence how surgery would proceed. First, the presence of intraorbital, intrafissural, and intracavernous foreign body components required that the surgical field be wide enough for complete exposure and removal. Second, the suggestion of damage to the right cavernous carotid artery and the possible need for direct repair mandated that proximal and distal control of the right internal carotid artery be obtained to avoid intraoperative hemorrhagic events. Third, the presence of an intraorbital abscess in the medial aspect of the orbit further emphasized the need for an extensive orbital exposure. Finally, findings at surgery would dictate the degree of reconstruction of the bony anatomy of the orbit and skull base that would be needed.
This multiplicity of problems called for a surgical strategy that would provide multiple solutions. Al-Mefty details an approach to the cavernous sinus which provides proximal and distal control of the internal carotid artery, isolation and control of all critical neurovascular structures in the region (including the intracavernous portions of cranial nerves III-VI), and multiple options regarding access into the cavernous sinus.14 In turn, lateral orbitotomy is particularly useful in the management of medial and apical lesions, which are especially difficult to reach due to the conical shape of the cavity.7,13 Furthermore, removal of the roof of the orbit exposes the entirety of the superior orbital fissure.7,15 Despite their individual merit, neither of these procedures in isolation would have addressed all of our surgical needs. A combination of these approaches, however, enabled us to remove the foreign body from the cavernous sinus under direct microscopic visualization and assess the cavernous carotid artery, to obtain direct access to that part of the foreign body passing through the fissure, to expose and drain the intraorbital abscess, and to completely control all surrounding structures.
Recommendations regarding reconstruction of the orbit remain equivocal.7,13,15 Given the finding of a purulent orbital abscess in this patient, we decided to refrain from bone graft reconstruction of the orbital roof. Again, the principle of flexibility in the treatment of traumatic injury must dictate intraoperative decision making.
Cases of retained intracranial foreign bodies causing delayed onset of neurological symptoms are rare. We discuss the unique presentation and surgical management of a patient who presented with delayed onset superior orbital fissure syndrome secondary to a retained foreign body invading the orbit and the cavernous sinus. Relevant issues regarding the diagnosis and workup of penetrating orbital and intracranial injuries, as well considerations in the planning of surgical approaches to traumatic insult of the orbit and the cavernous sinus are addressed.
- Pridioux E. Penetrating wound of the orbit involving the brain. Lancet 1882;2:846
- Miller CF II, Brodkey JS. Colombi BJ. The danger of intracranial wood. Surg Neurol 1977;7:95-103
- Pendas SL, Castro JMA. Traumatic superior orbital fissure syndrome: report of case. J Oral Maxillofac Surg 1995;53:934-936
- Grove AS. Computed tomography in the management of orbital trauma. Ophthalmology 1982;89:433-440
- Weisman AA, Savino PJ, Schut L. et al. Computed tomography in penetrating wounds of the orbit with retained foreign bodies. Arch Otolaryngol 1983;109:265-268
- Savino PJ. The present role of magnetic resonance imaging in neuro-ophthalmology. Can J Opthalmol 1987;22:4-12
- Bilyk JR, Dallow RL, Ojemann RG, et al. Management of lesions of the cranioorbital juction. Int Ophthalmol Clin 1992;32:73-93
- Parkinson D. A surgical approach to the carvernous portion of the carotid artery. Anatomical studies and case report. J Neusurg 1965;23:474-483
- Umansky F, Valarezo A, Elidan J. The superior wall of the carvernous sinus: a microanatomical study. J Neurosurg 1994;81:914-920
- Van Loveren HR, Keller JT, EL-Kallini M, et al. The Dolenc technique for carvernous sinus exploration (cadaveric prosection). J Neurosurg 1991;74:837-844
- Al-Mefty O. Surgical technique for juxtasellar area. In: Al-Mefty O (ed). Surgery of the Cranial Base. Boston: Kluwer Academic, 1989;73-89
- Dolenc V. Direct microsurgical repair of intracavernous vascular lesions. J Neurosurg 1983;58:824-831
- Al-Mefty O. Surgery of the orbit. In: Al-Mefty O (ed). Surgery of the Cranial Base. Boston: Kluwer Academic, 1989;153-164
- Al-Mefty O. Management of carvernous sinus involvement. In: Al-Mefty O (ed). Surgery of the Cranial Base. Boston: Kluwer Academic, 1989;91-106
- Pozzati E, Giuliani G, Gaist G. Orbital surgery: repair of the frontal fossa by 'en bloc' removal and self-replacement of the orbital roof. Surg Neurol 1988;30:159-161